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Randi Mundell’s CS Cluster
Comprehensive Program ReviewAugust 17, 2012
Athol, Brookfield, Paxton, Westboro, Windsor
CLUSTER HIGHLIGHTS Athol, Brookfield, Paxton, Westboro, Windsor
Unified team (staff) within programs that are distant from each other◦ Flexible in schedule to meet program needs and
individual needs during staff shortages and incidents
Windsor staff found bikes for individuals to help increase activity and promote healthy living, with no cost to program
All CT women involved in vocational programming and all Brookfield women involved in day programming
CLUSTER HIGHLIGHTS continued
Volunteer Opportunities for individuals:o Sherry House (clothing drive) ◦ Walk for Hunger (walked)o Habitat for Humanity (clean/stock) ◦ KOC (cleaning)o Local animal shelter (walked dogs)◦ Self-advocacy fund raiser o Local nursing home (serving food and companion)o Wrote letters to Soldiers and Malia (terminally ill child)
Community Involvement for individuals - INCREASED◦ Brookfield Bowling League – ALL 5 women◦ Horseback Riding lessons and horse show ◦ Paxton family cookout◦ Local gyms; churches memberships◦ Art and Music classes; guitar lessons ; dance classes and recitals ◦ art shows; museums; knitting classes (at local community center)◦ Small mechanics class (rebuilding go-carts); and enrolled in fall
college automotive courses
Far distance away from Shirley and Boston and other CS programs◦ Staff coverage is difficult due to this◦ Lack of interaction with others
CT staff are not required to complete a full Medication training as compared to MA staff◦ Increase in medication occurrences and incidents
Client medication refusals Staff turn over Funds needed for meaningful day supplies Integration of new intakes with peers and program
◦ Time consuming for staff and program◦ Limits staff involvement with other individuals, can lead to
increased behaviors◦ Difficulties trying to find common interests
Areas in Need of Improvement
STAFFINGOVERDUE PERFORMANCE EVALUATIONS
Data obtained from HR Department & HR Personnel Summary
0
1
2
3
4
5
6
4.5
1.6
4
0.5
6
3.32
Average: 3.3 Overdue FT Performance Evaluations January – June 2012
** Westboro – data from May & June only.
As of June 30, 2012, only 1 PT evaluation was overdue for the cluster.
Last CPR, average: 2.2 for overdue performance evaluations – included only Brookfield, Westboro, and Windsor.
Brookfield, Westboro, and Windsor average is 2.7 compared to the 2.2 last CPR.
STAFF TURNOVER RATE (7/1/2011 – 6/30/2012)
STAFFING
Athol
Brook
field
Paxt
on
Wes
tbor
o
Winds
or
Cluster
Ave
rage
CSMA
CSNH
Overa
ll- C
RJ
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
31.80%
11.80%
33.30%36.80%
27.30% 28.20%
23.50%
15.40%
24.70%
Data obtained from HR Department & HR Personnel Summary
Average: 1.12 medication incidents and occurrences per client/month
Total of 142 medication incidents and occurrences (January – June 2012
Last CPR, average of 2.4 medication incidents/occurrences per client/month. Last CPR included Brookfield, Westboro and Windsor, only
MEDICATION INCIDENTS & OCCURRENCES
AtholBrookfield
PaxtonWestboro
WindsorOverall Cluster
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
0.11
4.1
00.03
0.830000000000001 1.12
Average Medication Incidents & Occurrences Per Month Per Client
Data obtained from MMRs
AtholBrookfield
PaxtonWestboro
Windsor
0
0.5
1
1.5
2
2.5
3
3.5
4
2.67
2.17
3.91
1.571.5
Average Clinical Hours Per Client /Month By Program
CLINICAL HOURS
Average of 2.42 clinical hours per client/month
Total Clinical Hours = 305 (January – June 2012)
Last CPR, average clinical hours per client per month was 1.5 Last CPR included Brookfield, Westboro and Windsor, only
Data obtained from MMRs
Clinical hours include in-house individual service hours and
in-house clinical group service hours.
AtholBrookfield
Paxton Westboro
WindsorCluster
0
5
10
15
20
25
30
0.330000000000001 2.03
2.25
22.43
1.23
6.50.483.03
2.38
26.3
7.9 8.67
Partici-pated In
COMMUNITY INCLUSION
Average of 6.5 community inclusion activities were participated in per client/month, compared to 2.77 at the last CPR. (Last CPR included Brookfield, Westboro and Windsor, only).
Total of 891 community inclusion activities were participated in by all clients. Average of 8.67 community inclusion activities were offered per client/month. Total of 1093
community inclusion activities were offered Jan – June 2012.
Average Community Inclusion Activities Participated In and Offered Per Client/ Month (January - June 2012)
Data obtained from MMRs
MAINSTREAM COMMUNITY ACTIVITIES
Average of 15.75 mainstream community activities participated in per client/month, compared to 3.46 at the last CPR (April –Sept. 2011). (Last CPR included Brookfield, Westboro and Windsor, only).
Total of 1985 mainstream activities were participated in by all clients. Average of 19.53 mainstream activities were offered per client/month; Total of 2462 mainstream activities were offered in Jan – June 2012.
Average Mainstream Activities Participated In and Offered Per Client/Month(January - June 2012)
Data obtained from MMRs
AtholBrookfield
PaxtonWestboro
WindsorCluster
0
5
10
15
20
25
30
12.03
22.33
9.1312.53
21.88
15.75
14.52
25.2
12.8815.96
29.22
19.53
ParticipatedOffered
DE-ESCALATIONS & RESTRAINTS
Data obtained from MMRs
De-Escalations : Restraints January – June 2012
Athol 5.62:1
Brookfield 10:1
Paxton 22:1
Westboro 124:1
Windsor 6.76:1
Average - Cluster 33.7:1
Total De-Escalations/Restraints for This Period
1079/101
ElopementsJanuary – June 2012
Athol 8
Brookfield 0
Paxton 0
Westboro 3
Windsor 2
Cluster Total
13
Previous CPR (April – Sept.2011), • Average Cluster Ratio = 16.6:1
• Brookfield 13.3:1• Westboro 13:1• Windsor 23.6:1
4 Elopements reported
STAFF TRAINING HOURS
AtholBrookfield
PaxtonWestboro
WindsorCluster
0
100
200
300
400
500
600
700
800
900
1000
218 243
370
32 92
955
20.8 24 39.43.4 8.8 19.3
Total Hours Completed By Program Average Per Staff
Data obtained from MMRs
Average 19.3 training hours per staff
Total 955 training hours were completed January – June 2012
Last CPR, total training hours = 1,068. (Last CPR included Brookfield, Westboro and Windsor, only).
RESULTS OF SQA MONITORING AUDITS
CONFIDENTIAL FILES AVERAGE = 74%Positives ISP Documents were completed 100% in 4 out of the 5
programs Satisfaction Surveys completed 100% (2011)
Areas to Improve LOM/Restraint forms and the Behavioral data do not match in
4 out of the 5 programs Mandatory medical appointments
◦ Annual Physical examination 80%◦ Dental exam 80%◦ Vision Exams 80%
Acquiring mandatory signatures on the proper forms
RESULTS OF SQA MONITORING AUDITS
FINANCIAL RECORDS AVERAGE = 87% Positives All Resident Funds records matched the amount of cash on hand
(100%) All bank books were balanced (100%)Areas to Improve Budgeting Sessions 20% being completed correctly Accuracy of the Funds Management Teaching plans
PROGRAM FORMS AVERAGE = 80%Positives Fire drills completed (100%) and documented properly (91%) Up to date Safety plans with proper signatures (100%) Up to date
trainings (80%)Areas to Improve Up to date Carbon Monoxide training (40%) House meetings with proper documentation (40%)
Total of 22 clients in Randi’s Cluster Employment/Education: (as of June 30, 2012)
◦ 3 clients are employed◦ 4 enrolled in full-time education◦ 10 enrolled in sheltered workshops◦ 5 enrolled in pre-vocational or job training
Other:◦ Client incidents involving contraband was “0” this
reporting period. Last CPR, no contraband (“trigger items”) found in the programs.
KEY MMR RESULTS
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